Top 5 Ways to Prevent Falls

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Preventing falls in the SNF environment can be a challenge. Learn how to become a fall CSI and inspire your interdisciplinary team to meet the challenge of Falls Reduction. Improve patient care and survey outcomes.

1. Learn to detail the Benefit of Root Cause analysis.

2. Gain an understanding of the Fall Investigation process.

3. Develop a clear understanding of accurate coding in Section M.

4. Learn how to verbalize the benefit of interdisciplinary involvement and follow-up for Fall Events.

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Top 5 Ways to Prevent Falls

  1. 1. Top 5 Ways to Prevent Falls HARMONY UNIVERSITY The Provider Unit of Harmony Healthcare International, Inc. Presented by: Eileen Kelly, PT, RAC-CT Regional Consultant Joyce Sadewicz, PT, RAC-CT Field Operations and Regional Consultant
  2. 2. Speaker Bio (Eileen Kelly) Regional Consultant for Harmony Healthcare International, Inc, providing on-site auditing of the MDS and associated records for PPS and Case Mix purposes Education Physical Therapy degree from SUNY at Buffalo Masters Degree in Applied Anatomy and Physiology from Boston University MBA in Health Care Policy at Brandeis University Experience Adult Rehabilitation for NY State and MA Rehab Hospitals Rehabilitation Program Manager for Skilled Nursing Facilities, responsible for transitioning Therapy Departments into Medicare’s Prospective Payment System Considerable experience with DPH and JACHO Surveys Devised and implemented Quality Improvement Programs and collaborated with nursing to develop a CNA Career Ladder Program Extensive experience with third-party payment systems, including Medicare, Managed Care and Workers Compensation Medicare Specialist working with provider groups regarding performance management for one of the country’s leading Medicare Advantage Plans Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 2
  3. 3. Speaker Bio (Joyce Sadewicz) Field Operations and Regional Consultant for Harmony Healthcare International, Inc. Education Bachelor of Science in Physical Therapy from Russell Sage College and Albany Medical School Extensive knowledge in reimbursement and management of patient care Clinical Case Manager MDS and reimbursement in a PPS environment Knowledge of the RAI process in the Medicare PPS setting as well as the Case Mix setting Experience Over 15 years of experience in Physical Therapy, working with neurologically impaired children and adolescents Invaluable Physical Therapy experience working in acute care a city hospital with an active inpatient and outpatient program as well as a regional burn center and trauma unit Manager of the Physical and Occupational Therapy Departments Manager of the Work Tolerance Center, an outpatient work-hardening program Manager of 40 rehab personnel with a combined budget of $1.5 million in a 440 bed acute care setting with multiple outpatient sites Rehabilitation Manager in a long-term care facility Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 3
  4. 4. Top 5 Ways to Prevent Falls Disclosures: The planners and presenters of this educational activity have no relationship with commercial entities or conflicts of interest to disclose Planners: Elisa Bovee, MS, OTR/L Diane Buckley, BSN, RN, RAC-CT Beckie Dow, RN, RAC-MT Keri Hart, MS CCC, SLP, RAC-CT Kristen Mastrangelo, OTR/L, MBA, NHA Christine Twombly, RNC, RAC-MT, LHRM Presenters: Eileen Kelly, PT, RAC-CT, Regional Consultant Joyce Sadewicz, PT, RAC-CT, Field Operations and Regional Consultant Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 4
  5. 5. Harmony Healthcare International, Inc. Top 5 Ways to Prevent Falls Disclosure Speakers: Eileen Kelly, PT, RAC-CT, Regional Consultant Joyce Sadewicz, PT, RAC-CT, Field Operations and Regional Consultant The speakers have no relevant financial relationships to disclose The speakers have no relevant nonfinancial relationships to disclose Copyright © 2013 All Rights Reserved 5
  6. 6. Harmony Healthcare International, Inc. Top 5 Ways to Prevent Falls Criteria for Successful Completion Complete Sign-in and Sign-Out on Attendance Form Attendance for entire session Completion and submission of speaker evaluation form Copyright © 2013 All Rights Reserved 6
  7. 7. Harmony Healthcare International, Inc. 7 Housekeeping Sign In Contact Hours Certificate A Little About Us Handouts Contact Information for Questions Copyright © 2013 All Rights Reserved
  8. 8. Objectives The learner will be able to detail the benefits of Root Cause Analysis The learner will be able to discuss the process of a Falls investigation The learner will be able to verbalize the benefit of interdisciplinary involvement and follow-up Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 8
  9. 9. Falls in America Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 9
  10. 10. Falls in America How big is the problem? One in three adults age 65 and older falls each year. Less than half discuss with a healthcare professional. 20% to 30% suffer moderate to severe injuries that decrease mobility. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 10
  11. 11. Falls in America How big is the problem? In 2009 ERs treated 2.4 million non-fatal fall injuries among older adults. More than 662,000 had to be hospitalized. Among older adults, falls are the leading cause of death related to injuries. In 2010, the direct medical costs of falls, adjusted for inflation was $30.0 billion. By 2020, the annual direct and indirect cost of fall injuries is expected to reach $54.9 billion. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 11
  12. 12. Falls in Nursing Homes In 2003, 1.5 million people 65 and older lived in nursing homes. If the current rates continue, by 2030, this will rise to about 3 million. More people than Chicago, Houston, or Philadelphia. Each year a typical nursing home with 100 beds reports 100 to 200 falls. Many falls go unreported. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 12
  13. 13. Falls in Nursing Homes Between half and three-quarters of nursing home residents fall each year Twice the rate of falls for older adults living in the community Patients often fall more than once. The average is 2.6 falls per person each year. About 35% of fall injuries occur among residents who cannot walk Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 13
  14. 14. How Serious Are These Falls? Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 14
  15. 15. How Serious Are These Falls? About 1,800 people living in nursing homes die each year from falls About 10% to 20% of nursing home falls cause serious injuries; 2% to 6% cause fractures Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 15
  16. 16. How Serious Are These Falls? Falls result in: Disability Functional decline Reduced quality of life Fear of falling Loss of function Depression Feeling of helplessness Social isolation Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 16
  17. 17. Why Are There More Falls In Nursing Homes? Other health problems Generally more frail than older adults living in the community Older, with more chronic conditions More difficulty walking Thought or memory problems Difficulties with ADLs Need assistance with mobility Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 17
  18. 18. Common Causes of Falls in Nursing Homes Muscle weakness and gait difficulties (24% of falls) Environmental hazards (16% to 27%) Medications Other causes (Poor foot care, poorly fitting shoes, improper use of walking aids.) Low vision Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 18
  19. 19. What is the Cost of Doing Nothing? Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 19
  20. 20. What is the Cost of Doing Nothing? A jury has awarded $1.1 billion in damages to the family of a Florida woman who received poor nursing home care prior to her death in 2007. The family alleged that she often fell, and received inadequate supervision. The jury took an hour to deliberate and awarded $110 million in compensatory damages and $1 billion in punitive damages. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 20
  21. 21. What is Your Current Fall Risk Picture? Know your fall statistics Analyze the data Use scatter analysis to help identify trends Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 21
  22. 22. 5 Steps to an Effective Fall Management Program Development of the Interdisciplinary Team Assess, Assess, Assess Root Cause Analysis Falls CSI Follow-up Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 22
  23. 23. Interdisciplinary Team Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 23
  24. 24. Interdisciplinary Team Team Leader CNAs Administration Nursing Rehabilitation Activities Dietary Housekeeping Maintenance Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 24
  25. 25. Interdisciplinary Team Team Leader Task Goals Decision making Training Maintain standards Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 25
  26. 26. Interdisciplinary Team Team Leader Relational Coaching Collaborating Manage conflict Build commitment Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 26
  27. 27. Interdisciplinary Team Team Leader Environmental Share Information Buffering Assessing Advocating Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 27
  28. 28. Interdisciplinary Team Why CNAs? They spend more time with patients than anyone else They know more about the patients than you think They need to be empowered to report problems and suggest solutions Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 28
  29. 29. Interdisciplinary Team Administration Support the program Support the team Filter down the importance of the program and results. Talk the talk, walk the walk! Share information with the team Quality Assurance, Performance Improvement Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 29
  30. 30. Interdisciplinary Team Nursing Patient assessment Care Planning Medications Vision Follow Through Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 30
  31. 31. Interdisciplinary Team Rehabilitation Patient Assessment Screening vs. Treatment Visual Assessment Environmental Assessment Assess for proper footwear Care Planning Follow Through Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 31
  32. 32. Interdisciplinary Team Activities Patient Assessment Provide meaningful diversional activities Assist with identification of fall trends and solutions Exercise classes Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 32
  33. 33. Interdisciplinary Team Dietary Patient Assessment Identify patients at risk for fractures Maintenance of strong bones through diet Identify patients at risk for dehydration Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 33
  34. 34. Interdisciplinary Team Maintenance Environmental Hazards Lighting Environmental Aids Preventative Maintenance Program for beds, wheelchairs, and walking aids Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 34
  35. 35. Interdisciplinary Team Housekeeping Environmental hazards Placement of furniture Location of bed linens Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 35
  36. 36. Resident Assessment Who assesses the resident? When are the residents assessed? How are the results communicated to the staff? How are the results used to develop a fall program for the resident? Which patients should have a fall program? Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 36
  37. 37. Resident Assessment The 30-Second Chair Stand Test The Timed Up and Go (TUG) Test The 4-Stage Balance Test Orthostatic Blood Pressure Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 37
  38. 38. OK, I have a patient on the floor! Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 38 Now What?
  39. 39. “Most people see what they want to, or at least what they expect to.” -Martha Grimes Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 39
  40. 40. Falls CSI Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 40
  41. 41. CSI of Falls Why draw a picture or take a photo? Someone else may find a contributing factor to the fall that was unseen by the first responder Eye witness memory is not reliable Memory can be affected by stress or mood Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 41
  42. 42. Kitchen Test Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 42
  43. 43. How good is your visual memory? Is the child a boy or girl? What color is the child’s shirt? What is dripping from the refrigerator? Name all items on the floor? How many eggs are on the refrigerator door? Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 43
  44. 44. Root Cause Analysis Traditional Models of looking at adverse events have focused on holding an individual responsible Root Cause Analysis (RCA) guides you to look at systems and what made it possible for the adverse event to happen Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 44
  45. 45. Root Cause Analysis Gather and document initial information Fill in the gaps Analyze (The 5 Whys) Develop an Action Plan (SMARTS) Evaluate Effectiveness (PDSA) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 45
  46. 46. Root Cause Analysis Gather and Document Initial Information Interview staff and others closely involved What do you think happened? Use open ended questions, “Tell me about…” Make a diagram of the scene at the time of discovery Draw a stick figure to indicate where the resident was found/fell (label as face up or face down) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 46
  47. 47. Root Cause Analysis Fill in the Gaps, Review Findings Identify any gaps and gather any missing information (review record, fall history, interview/re-interview, plan of care) Outline the sequence of events leading up to the fall List possible contributing factors Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 47
  48. 48. Root Cause Analysis Identify Contributing Factors Possible contributing factors to consider: Environment and equipment related Medication related Communication related Identified fall prevention/risk interventions in place? Care plan appropriate, updated and followed? Use the 5 Whys to uncover root causes Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 48
  49. 49. Root Cause Analysis The 5 Whys This is a question asking method used to uncover the underlying cause of an event Uncovering the root cause(s) leads to action plans that are more likely to prevent the event from happening again Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 49
  50. 50. Root Cause Analysis Why •Resident fell in room Why •She tripped over a chair Why •She didn’t see the chair Why •The room was dark, no nightlight Why •Nightlight was not part of the Care Plan Why •Resident assessed as NOT at risk for falling Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 50 Plan: Remove or move the chair Plan: Put nightlights in all patient rooms Plan: Review fall risk assessment process; update if needed
  51. 51. Root Cause Analysis Environmental Factors/General Lighting Flooring (wet, shiny, contrast, uneven) Furniture placement Room to move freely in the turn radius Others present, residents, staff visitors? Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 51
  52. 52. Root Cause Analysis Environmental Factors/Equipment Defective/nonworking equipment Equipment design Use specified in Care Plan? Appropriate for resident? Correct placement? Entrapment/safety risk? Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 52
  53. 53. Root Cause Analysis Medications/General New? Changes? (Dose, time) When was last dose given? Has there been a medication error in the last 24 hours? Side effects (weakness, dizziness, acute delirium) Interactions (drug-drug, drug-food, drug-herb) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 53
  54. 54. Root Cause Analysis Communication Factors MD or NP Hand off or shift report Resident transfer Available information Between departments Between healthcare professionals and family Other organizations HARD TO READ HANDWRITING/FAXES Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 54
  55. 55. Root Cause Analysis Evaluation of Effectiveness Test the plan Plan Do Study Act Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 55
  56. 56. Root Cause Analysis Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 56
  57. 57. Root Cause Analysis Implement the plan and assess for effectiveness Track and trend data over time Share results with Safety and Quality committees Update Care Plan and communicate to team members and all staff Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 57
  58. 58. Follow Up - Model for Improvement Two Step Process Three fundamental questions can be asked in any order The Plan-Do-Study-Act Cycle to test and implement change Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 58
  59. 59. Three Questions What are we trying to accomplish? The aim should be time-specific and measureable Use SMARTS goals to help set your aim Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 59
  60. 60. Three Questions How will we know that a change is an improvement? Establish measures Quantitative measures will help you determine that a specific change leads to an improvement Track and trend your data over time Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 60
  61. 61. Scatter Analysis Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 61 0 5 10 15 20 25 30 35 40 0:00 2:24 4:48 7:12 9:36 12:00 14:24 16:48 19:12 21:36 0:00 Number of Falls in 6 months Number of Falls in 6 months
  62. 62. Three What change can we make that will result in an improvement? Identify the change that will most likely lead to an improvement Start small, perhaps with one nursing unit at a time Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 62
  63. 63. Plan-Do-Study-Act Study or Check: Assess the change for a specific period of time to determine if the change was effective Have team members report back to the team on the effectiveness of the change Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 63
  64. 64. Plan-Do-Study-Act Act: Implement the action plan or start the process over again Celebrate success Return to the process if the plan has not worked Track and trend data over time using graphs and charts Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 64
  65. 65. What Works? Staff Education Vision Awareness Frequent rounding by nursing/CNA staff Same staff, same patient Eliminating wheelchairs Meaningful activities Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 65
  66. 66. References CDC: http://www.cdc.gov/HomeandRecreationa lSafety/Falls/index.html Oregon Patient Safety Commission: http://oregonpatientsafety.org/healthcare- professionals/nursing-homes/long-term- care-falls-investigation-toolkit/284/ Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 66
  67. 67. References Oregon Safety Commission http://oregonpatientsafety.org/healthcare- professionals/nursing-homes/root- cause-analysis-materials-for-long-term- care-facilities/283/ Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 67
  68. 68. Questions/Answers Harmony Healthcare Internationa 1 (800) 530 – 4413 ekelly@harmony-healthcare.com jsadewicz@harmony-healthcare.com Harmony Healthcare International, Inc. 6868Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc.
  69. 69. Harmony Healthcare International Have you Considered a Customized Complimentary HARMONY(HHI) MEDICARE PROGRAM EVALUATION or CASE MIX ANALYSIS for your Facility? Perhaps your facility has potential for additional revenue Assess your facility against key indicators and national norms Email us at for more information RUGS@harmony-healthcare.com Analysis is cost & obligation free Harmony Healthcare International, Inc. 69Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc.

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